Splitting Complex Post-Traumatic Stress Disorder and Borderline Personality Disorder

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Complex Post-Traumatic Stress Disorder (C-PTSD) has long been hailed as a beacon of hope in the maze of psychiatric diagnoses, even among those of us who have felt harmed by such labels. It offers a fresh perspective on the relentless, pervasive trauma that acts more as a sculptor than an event—a relentless chiseler that etches seemingly indelible patterns and erects defensive fortresses so deeply embedded in our being that they seem less like experiences we’ve weathered, and more like integral fragments of our identity.

When ICD-11, the diagnostic manual used by Europe and half the world, recently acknowledged C-PTSD, it was perceived as a potential breakthrough for those of us profoundly impacted by such trauma. Expectations were high for increased understanding, empathy, and support. However, the rapidly changing landscape suggests that the recognition of C-PTSD might be a double-edged sword, inadvertently further marginalizing the very individuals it aimed to assist—those diagnosed with Borderline Personality Disorder (BPD). Why?

Vector style illustration of a woman hugging her knees with cloudlike scribbles on a blue-gray background

The Emergence of C-PTSD

Borderline Personality Disorder (BPD) is a diagnostic category characterized by fluctuations in mood, self-image, behavior, and relationships. People so labelled commonly experience intense emotional swings, impulsivity, unstable yet intense relationships, and a pervasive sense of overwhelming emptiness. Clinicians often diagnose BPD when encountering individuals, primarily women, who engage in self-harm, with females representing 70% of those diagnosed. This association with femininity does a disservice not only to women but also to men and non-binary folk in pain, as it perpetuates a misogynistic trope that dismisses patients as ‘attention-seeking’, ‘manipulative’, and ‘playing the victim’.

Telling someone that their personality is disordered is a violent thing to do, implying that the problem is with who they are, rather than a syndrome they have, or an understandable response to horrific life events. Ascribing problems to personality suggest that patients were always defective or wrong and always will be, often perpetuating survivors’ deepest fears about themselves. The label of BPD not only diminishes the testimonial credibility patients give to themselves but enables harmful reactions from healthcare professionals, family members, and society, hindering their access to necessary care. This re-traumatizes many survivors by reproducing the distance, contempt, abuse, and neglect that were often dominant in early life, increasing hopelessness and self-hatred. The majority of those diagnosed with BPD are trauma survivors, with approximately 70% scoring high on adverse childhood experience measures, being especially likely to have experienced emotional and sexual abuse.

Trauma therapist Judith Herman first suggested C-PTSD as an alternative diagnosis to the BPD label in 1992. Her reasoning was straightforward: she knew that the label was frequently perceived as stigmatizing and injurious by trauma survivors, often amounting to no more than a ‘sophisticated insult.’ Additionally, she argued that the existing trauma category of Post-Traumatic Stress Disorder (PTSD) only addressed reactions to isolated, one-off traumatic events, like flashbacks. C-PTSD was thus proposed as a diagnosis to encompass the unique symptomatology resulting from chronic, recurrent trauma experienced over an extended period, such as enduring child abuse, domestic violence, or imprisonment during wartime, rather than from a singular traumatic incident.

Herman defines C-PTSD with symptoms grouped into three main areas: 1) affective impulse regulation, covering emotional regulation issues, suicidal and self-destructive behaviors, and impulse control problems; 2) alterations in attention or consciousness, manifesting in dissociation episodes, flashbacks, and changes in self-perception like persistent guilt and estrangement; 3) changes in self-perception and relationships, marked by withdrawal, distrust, a rescuer-seeking behavior, distorted beliefs about the perpetrator, and loss of faith or hopelessness.

Herman’s suggestion, which had been built not only off the work of her patients but the labour of survivor movements, was initially met with controversy. However, as the subsequent three decades unfolded, the idea of C-PTSD gained increasing acceptance. This progression happened in parallel with significant and ongoing shifts in societal recognition of trauma. What was once deemed uncommon began to be acknowledged as remarkably prevalent—with one in four of us having been abused.

Throughout this time, attitudes towards trauma underwent a remarkable metamorphosis, a shift partly propelled by the influential reach of self-help literature and the emergence of daytime television programs that dared to delve into mental health issues. Names like Oprah Winfrey, Jeremy Kyle, and Ricki Lake became synonymous with these candid on-screen discussions. Self-help books such as Pete Walker’s Complex PTSD: From Surviving to Thriving and others began to fill shelves and later screens, providing resources for understanding and managing trauma.

The pathway towards including C-PTSD necessitated a convergence of societal change, psychological activism, and scholarship. However, as Judith Herman warns, the recognition of trauma is perpetually threatened by the risk of regression. This regressive pull is as prevalent in large organizations as it is within an individual’s psyche, where the desire to suppress traumatic experiences can trigger a fierce backlash, manifesting in a maelstrom of distressing symptoms. C-PTSD appeared useful not least as a placeholder then.

Not everyone was in favour of the C-PTSD category, however. Some disagree with the term ‘disorder’ to describe the aftermath of trauma, viewing it as the medicalization of understandable trauma effects. Nevertheless, many saw in C-PTSD a potential diagnostic home. Thus, when C-PTSD was officially approved as a diagnosis by ICD-11 in 2019, to be introduced into clinical practice from Jan 2022, it was met with widespread relief and celebration. But was this relief premature?

‘Doing’ C-PTSD

Before we go on, a note. If we are to have a diagnostic system, I support the inclusion of C-PTSD. I eagerly welcome the increased training it will provide for clinicians, helping them to understand the profound impact of prolonged trauma on our minds, bodies, and souls. However, we face a significant challenge in our mental health thinking, including among those who are critical. We often overlook the interconnectedness of ideas and fail to anticipate how they might affect one another. Just like a single keystroke can reshape the meaning of a word, the addition of C-PTSD sends ripples throughout the diagnostic system, reshaping other constructs in its wake. These ripple effects can be perilous, potentially undermining the very positives that survivors and trauma therapists were striving for.

From this position, C-PTSD is much more problematic. While one might intuitively expect C-PTSD to provide a nosological refuge for those who’ve lived through protracted trauma such as enduring childhood sexual, emotional, or physical abuse, or neglect—as the label on the bottle suggests —the reality is far more complicated. The category’s strict definition ironically creates an exclusionary boundary, leaving out as many individuals as it shelters.

What’s even more concerning is the emergence of a growing industry of articles, YouTube videos, TikToks, and infographics that appear more focused on establishing a distinct position for C-PTSD within the diagnostic landscape by emphasizing what it is not, rather than providing a clinical picture of what it is. And what do they contrast it with? BPD, the closest phenomenological neighbour to C-PTSD. When a category is new, we tend to spend a lot of time trying to give it bones, hence the flurry of activity right now. We do this both by comparison with something very different and something very similar. If I am trying to define what a cookie is, for example, I might do it by contrasting it with a cake.

Comparing two pictures cements the seemingness of both categories just as were I to try to describe to you the differences between Santa Claus and Hanukah Harry both would become more vivid. This brings us to the first of our problems. In the process of so doing, C-PTSD unintentionally reinforces one of the most problematic diagnostic categories of our time, BPD. This comes at a moment when it seemed that progress was finally being made after forty years of dogged survivor activism, fueled by the often-invisible labour of many we have lost, and many who are still here.

Solidifying BPD

In the UK, there has been a growing sense of change in the air surrounding the diagnosis of BPD. Recent developments, including a national consensus paper endorsed by prominent organizations, have called for the abandonment of the BPD label. This is not only due to the exceptionally poor construct validity of BPD, which renders it a scientific embarrassment even to mainstream clinicians, but also because of the contempt it so often engenders within our care systems and the despair it causes many survivors. These developments, along with a series of recent scandals, has sparked active reevaluation of the diagnosis and language used by both the Royal College of Psychiatrists and NHS England. In line with the changing landscape, the influential NIHR-funded Mental Health PRU has taken a proactive step by adopting the term “complex emotional needs” as a working title, signifying a gear change, a move in the right direction, albeit one that fails to go nearly far enough.

And no wonder! Not only does BPD have exceptionally poor levels of reliability and validity, but it provokes high levels of discrimination and notoriously poor treatment not only in society but from healthcare providers. Though the intensity of distress experienced is undoubtable, the natural history of BPD suggests that it is reflective of emotional, and not personality, difficulties; recovery within a ten-year window being at 85%. Further, the BPD diagnosis has low functional utility, often blocking access to help, and can solidify patients’ ideas that they are fundamentally flawed, i.e., that problems lie in who they are, not in a condition that they have.

These problems with BPD as a category, so severe it was to be removed from the latest iteration of the ICD until the very last moment, are entirely absent from C-PTSD vs BPD comparison-making. Instead, BPD’s distinct essence, its BPD-ness, is at risk of being re-solidified just as we seemed to be on the verge of unravelling the infamous ‘dustbin diagnosis’ that leaves people discarded and overlooked including the many who are not, or not only, traumatized but #ActuallyAutistic.

Worse, the way the comparison is presented gives the impression that there are significant differences between the diagnoses that are not only useful and meaningful but agreed upon. When we explore the mooted differences though, this is not the case. So, let’s park the construct problems with the BPD diagnosis for the moment to see what these apparent differences are. To do this, we need to see how C-PTSD is diagnosed.

Diagnosing C-PTSD

First, patients need to have experienced—you’ve guessed it—complex trauma. Now, there are important discussions to be had about the likelihood of this showing up in psychiatric assessments, but we’ll leave that for another time.

Then, a patient needs to meet the criteria for a diagnosis of PTSD as traditionally defined, which is now referred to as type 1 trauma. This involves re-experiencing the trauma in the present, exhibiting avoidance behaviors, and experiencing a persistent sense of current threat such, as is always the case with psychiatric diagnosis, that it causes significant suffering and/or affects functioning. Despite the need to meet the criteria for PTSD type 1, patients with complex trauma are unlikely to have received such a diagnosis before the introduction of C-PTSD. The chronic and cumulative nature of their trauma creates a less clear distinction between a ‘before and after’ scenario, as the defensive structure built up to protect the psyche is often mistaken for personality rather than being attributable to discrete traumatic events that can be more easily identified.

Now, we get to the gritty bit. C-PTSD, or type 2 trauma, then requires three additional criteria of so-called ‘Disturbances of Self-Organization’ (DSO): these are problems with emotional regulation, disturbances of self, and interpersonal problems. The DSO are crucial to our argument, so let’s expand on what psy-professionals generally mean by these terms, parking the problems with the hegemonic normativities that they are shaped from for the time being:

  1. Problems in Emotional Regulation: This refers to difficulties managing emotional responses, which can often lead to a person experiencing emotions that are intense and fluctuating and struggling with self-destructive or risky behaviour. People with these problems might have trouble calming down once upset or may struggle to cope with supposedly negative emotions in healthy ways. It can also include periods of emotional numbness or disconnection.
  2. Disturbances of Self-Concept: This is when a person has a negative and persistently unstable self-view. It means that the individual often feels worthless, defective, or as if they’re fundamentally different from other people. They may struggle with chronic feelings of emptiness, shame, guilt, or of being a failure. This often results from the internalization of the negative messages received during the traumatic events.
  3. Interpersonal Problems: This refers to difficulties in forming and maintaining relationships with others. These can be characterized by an avoidance of relationships due to mistrust, or a pattern of unhealthy or unstable relationships. The person might feel a persistent sense of disconnection or isolation from others, or they may struggle with boundaries, either being overly dependent or excessively self-reliant.

All of this bears an uncanny resemblance to how BPD is defined, doesn’t it?? BPD, after all, is supposedly a pattern of instability in emotions, self-image, and relationships, quite literally the DSO criteria. Intense and unstable emotions, impulsive behaviors, self-destructiveness, chaotic relationships, recurring thoughts of self-harm—all things associated with BPD seem to fit like a glove.

It’s no wonder then that most clinicians, professionals, and carers held the belief that individuals stamped with the BPD label who have experienced trauma would finally have a home in this new diagnostic label. But alas, that’s not proved to be the case. ICD-11 and the beholden research community decided to throw a curveball by introducing specific criteria, not just to determine IF emotional regulation issues, disturbances of self-concept, and interpersonal problems are present, but to delve into HOW they manifest. This occurred alongside a last-minute U-turn, indicating that BPD, a diagnostic category that has been found scientifically problematic by each and every DSM and ICD taskforces since its inception, still persists as a ‘trait qualifier’ in the ICD. This descriptor code allows it to remain as usable, as character assassinating, and as potentially damaging as it has been in the past.

Do the differences in how problems in emotional regulation, self-concept and interpersonal problems, then, hold enough weight to warrant such a clear-cut distinction, even if we were to accept BPD as a valid and distinct category on its own? Or are we simply witnessing a situation similar to segregating cardigans on one floor of a department store and sweaters on another, prompting us to ponder the motives behind this division and whose interests it truly serves—the business or the customer?

The Narcissism of Minor Differences

What differences are used to separate the DSOs of C-PTSD and BPD, then, and what does, and doesn’t that tell us?

Both diagnoses involve interpersonal problems, yet BPD is supposedly characterized by more unstable relationships involving idealization and denigration, while C-PTSD is associated with consistently negative relationships and a tendency to withdraw. Both emphasize issues related to self-concept, but the BPD construct is linked to rapid shifts in self-image, while C-PTSD is marked by a consistently negative self-view and struggles with worthlessness and guilt. Emotional dysregulation is present in the description of both supposed disorders, but BPD is more closely associated with self-harm and suicidal thoughts or actions, while C-PTSD is linked to reactive anger.

Upon scrutiny of the supposed differences, we uncover two underlying themes. Firstly, there’s a slightly more changeable presentation in the BPD grouping compared to the C-PTSD one. This variation could unsettle professionals’ self-image as adept caregivers. Recognizing the intersubjective nature of emotions—how our feelings resonate with those around us and their views of us—is vital. When a patient’s attitude shifts between interest, indifference, and disappointment, it can bruise a professional’s self-image. If inadequately trained, many resort to weaponizing the BPD label as a defensive reflex, thereby avoiding the sometimes-confronting reality of trauma responses as a necessity for survival, which, with the right understanding, deserve respect and admiration. Ascription to personality for one grouping, then, says far more about professionals’ trainings and the systems they operate within than much else.

The second theme centres on minor deviations from traditional hegemonic norms of femininity, including stability, submission, and preservation of the physical self, especially the fetishized female body. It’s disconcerting to see how our diagnostic systems mirror society’s unease with those who step away from the norm and who unflinchingly show their trauma—through physical signs or attempts to spur recognition among professionals and significant others. The BPD label, in this context, can be seen as a punitive form of regulation, steering treatment towards behavioural management and compliance, therein reinforcing hegemonic norms while dodging the need to face the harsh realities of human cruelty and the deep pain it inflicts.

Yet here I am giving a far greater impression of the suggested difference between BPD and C-PTSD than there is, a common outcome of descriptive comparison! We are discussing minor differences in not the presence or absence of, but the way emotional dysregulation, self-concept and interpersonal problems manifest here. While there is considerable symptom overlap across various diagnostic categories, and individuals often receive multiple diagnoses, the overlap between BPD and C-PTSD is quite extraordinary. Even the proposed differences just discussed are hypotheses rather than established facts for even the most mainstream researchers. A clinician is more likely to encounter a patient exhibiting symptoms of both supposed conditions than not. Yet, the way Guideline Development Groups organize—in sub-chapters 6B for ‘personality disorder’ and 6D for stress disorders—creates an illusion of distinctness.

This perceived distinction also arises from the fact that not all individuals diagnosed with BPD have experienced complex trauma—about 30% have not. Such a statistic could offer a persuasive case for maintaining a distinction between BPD and C-PTSD, if two conditions were fulfilled: a) BPD showed solid reliability and validity as a diagnostic category, and b) there were specific treatments exclusively ‘for’ BPD, which would then deprive trauma survivors of these treatments if they were excluded from this category.

However, BPD’s reliability and validity is so poor even the chair of the ICD taskforce called it an ‘abrogation of diagnosis’, and it was to be removed from ICD until a very last-minute U-turn, based predominantly on concerns about how health insurance claims would be coded. Treatments ‘for’ BPD, such as Dialectical Behaviour Therapy (DBT), Mentalization-Based Therapy (MBT), and Transference-Focused Therapy (TFT), address underlying common factors that are transdiagnostic, not exclusive to BPD, and are highly likely to be useful for many patients who will now get a label of C-PTSD. Furthermore, a recent meta-analysis has shown that trauma therapy is both safe and highly effective for trauma survivors diagnosed with BPD. Therefore, the division between BPD and C-PTSD is neither necessary, useful, scientific, or ethical. Treatment pathways should emphasise choice, a key predictor of good outcome.

Even if these minor differences were indeed supported by substantial evidence, there would be no inherent justification to shy away from labelling them as C-PTSD type 2.1 and 2.2, for survivors who favour diagnostic categories or need one to navigate statutory systems, such as access to welfare. I present this not as a genuine suggestion, but as a reflection of the absurdity of the filing system that assigns ‘personality’ to one group and ‘complex trauma’ to another when their family resemblance is so overwhelming.

Exclusion from C-PTSD

What is entirely missing, at least from professional discussions, is any real consideration of the impact of being excluded from the new category of C-PTSD, particularly for vulnerable patients. What does it mean for someone who has experienced complex trauma to have their patterns or behaviors placed in the ‘personality’ side of a Venn diagram presented as fact on Instagram, rather than being recognized as part of a trauma-centered label? To ask one’s psychiatrist if one meets criteria for C-PTSD now it exists as a diagnosis only to be told, ‘no, it’s definitely a personality disorder’? To stand up to abusive partners, poisonous family members, unsympathetic healthcare professionals, and barristers vying for custody of our kids, only to be met with the contemptuous retort, ‘If they genuinely believed you were traumatized, they would have diagnosed you with C-PTSD, wouldn’t they?’

No-one seems to have thought to ask—but any survivor, I reckon, can tell you without a second’s thought. Traumatized children and adults who are abused, groomed or gaslit are very often told that their trauma is not legitimate somehow; that the ‘real’ victims are over there and that we are too seductive, too difficult, too wily, too angry, too impulsive, too complicit somehow to be believable, let alone worthy of care and compassion Having trauma registered as such is thus incredibly important for us as survivors because we have nearly always been told otherwise in messages that can echo in the thoughts and voices that haunt us.

We are at a crucial turning point in the mental health system’s understanding, or lack thereof, of trauma—a point that presents many possibilities and pitfall. We must ensure that C-PTSD does not become a silencing tool, muffling the voices it was specifically designed to amplify and empower. This requires challenging the diagnosis of BPD, instead of using it as a foundation for defining C-PTSD, thereby avoiding the bifurcation of ‘deserving’ and ‘undeserving’ victims which has been used to silence and smother trauma survivors’ testimonies for centuries. Let’s fulfil C-PTSD’s promise and bin the diagnosis of BPD once and for all!

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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53 COMMENTS

  1. This is an awful dilemma.
    From my point of view, the label CPTSD carries the danger of dragging even more traumatised people into the jeopardy, discrimination, and punishment wrought by those already labelled as, effectively, dangerous, nasty manipulators who deserve punishment.
    Of course people who are suffering don’t want that, and many wish for a means to purge any descriptive trauma label of those so designated – simply in order to save themselves.

    It would be extremely unethical, but it would be interesting to randomly pick a section of physical health patients and put BPD on their records for a period to see how they fare in the physical health system, and also to measure their physical and especially, mental health over time compared to matched controls.

    I dont have any doubt about the results of such an experiment. Health treatment and subject health would plummet.

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  2. Two years ago I terminated therapy after 11 years of faithfully going every Thursday evening. As warm and kind and “fluffy” as my therapist was, I was picking up on something I knew was off.

    I did not know what it was, but I knew that something was not right. She didn’t validate me, she did not give me any psycho education and I started learning things from You-tube.

    I took a boundaries class; I learned the concept for the first time and I tried to bring what I learned into session—nothing. Warm, kindly face- no dialogue. In fact the no dialogue should have been a red-flag from the beginning, but I just did not know.

    I felt like I was being silently analyzed but never helped. We just aimlessly wandered and I kept wondering when we were going to actually do therapy. I surmised that this was her “method”.

    Oh, I had a trauma history. The worst trauma I ever experienced was 525 days as a nineteen year old in two different facilities because of a suicide attempt. It was 1986-87, but the horror still haunts my dreams; not so much my awakenings anymore.

    I never saw a psychiatrist since that nightmare decades ago, and consider myself fortunate to have learned that lesson.

    But I mistakenly thought therapy was safe. I had a psychology student help me immensely as I tried to navigate life and college.

    The helpful psychologist while I was in college wanted me to tell what had happened- he said that’s how I would heal.

    I believed him.

    After terminating with my therapist, and reading many articles on GoogleScholar, I now know that any mention of childhood trauma will get you “othered” and no one should ever know your trauma-particularly, a mental health “professional “.

    I was stunned when I read my therapist’s notes and realized she thought I had BPD-that was the “something” I had picked up on. I was in disbelief.

    She was warm and kind, so I told her of my trauma and I’m guessing because of the suicide attempt, I was othered”. I do not know-I don’t even fit into the box in which she placed me – I was shocked and sickened and this article brought it up.

    I applaud all of you who recognize this bigotry and violence and call it out. I applaud you for wanting to help others in your field possibly reflect on themselves and their own belief systems. But, it doesn’t matter what you call it- the name- what you categorize symptoms as- whether you use the word “disorder “ or not, because the problem lies within the individuals who are doing the treatment.

    I am a prime example. I did not know I was officially being “othered”, my therapist was consistent, warm and respectful, and yet I picked up on the undercurrent.

    Change will not occur because of nomenclature, but because these people who hold the vulnerable stories of their clients are themselves first healed before they ever see a client.

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  3. “Some disagree with the term ‘disorder’ to describe the aftermath of trauma, viewing it as the medicalization of understandable trauma effects”

    I couldn’t agree more, and coincidentally just had this published today: https://cptsdfoundation.org/2023/06/22/examining-the-d-in-cptsd/

    I think Jay’s article here is a great look at what goes wrong with labels and diagnoses in general. We treat them as if they explain something, when in fact all they do is describe symptoms. This fundamental error is in my view what drives a lot of subsequent misunderstanding, shame, and judgement.

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  4. They’ll always find new ways to hurt us. There will always be powerful people in the system who want to keep patients in their place, discredit them, dehumanize them.

    As I was reading this article, a memory from 15 years ago surfaced. After ECT for “treatment resistant depression” (I hadn’t responded to six years of drugging with SSRIs, SNRIs, Klonopin and, finally, Adderall), I was given this BPD label — that was the psychiatrist’s explanation for why the ECT hadn’t “worked.”. His attitude was that I had tricked him into believing that I was sad, when really I was just bad.

    I went to DBT as told, and when the DBT clinician told me to join AA, I did that too. I told people in my AA women’s group about how I had BPD (I thought I was supposed to tell people), and most of them distanced themselves from me but one of them, who worked in health care, immediately asked, “Who did you piss off?”.

    I didn’t really understand the question at the time, or rather I kind of understood it but wanted very much not to understand it because if I understood it then I would need to quit treatment and then I’d be really screwed because I had already lost everything while getting “help” and if I quit treatment I would lose the little bit of support that remained. (And would it prove I was borderline because borderlines “are famous for dropping out of treatment”?)

    In retrospect, I’m pretty sure I pissed off the ECT doctor when I tried to report his colleague for not keeping any records of six years of treatment. For six years, I had only assumed that that Dr was keeping records of the avalanche of “safe and effective” (this was the 90s) drugs he was prescribing. I only found out that he had kept none when the ECT Dr requested them.

    I had what they described as a fit while they said things like, “he was doing that to protect you.”. Because, like, I was the criminal here, was the suggestion.

    I called the APA and was shocked to learn that they didn’t think it was a big deal, either.

    That’s part of the story of how I “became” a borderline in my late 30s.

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  5. In mental health the notion of complexity serves as a ‘get out of jail’ card for clinicians. But at the same time it decreases the clinicians sense of self-efficacy, placing them on a pathway to burnout. Clients are likely to be aghast, that they are a ‘complex case’, adding further to their demoralisation. ‘Complexity’ offers training bodies a new vehicle through which to market their wares. With naïve clinicians scampering to sign up for workshops.
    The notion of Complex PTSD was rejected by the DSM-5 Committee on the grounds that it had no added value over a PTSD diagnosis. The DSM-5-TR criteria include a trauma related , sense of disconnection from others, beyond just being ‘out of sync’ and it can be specified whether the PTSD is with or without dissociative symptoms. There is thus no obvious added value in the Complex PTSD diagnosis. ICD has always been a much looser categorisation of mental disorders and it is no surprise that Complex PTSD has found its way into the World Health Organisations missive. But there is no compelling clinical evidence of the distillation of a more potent therapeutic intervention.
    In my book Personalising Trauma Treatment: Reframing and Reimagining published last year by London: Routledge, I quite deliberately did not use the construct of Complex PTSD. Nor have I used it in the writing of the 2nd Edition of my self-help book Moving on After Trauma London: Routledge (In Press). But in the clinical book I do give an example of helping a client who had laboured for over 20 years under the mistaken belief that he had PTSD as a result of child abuse. Treatment based on the PTSD diagnosis had been wholly ineffective. Using the the SCID standardised semi-structured interview which begins with an open-ended interview I made a diagnosis of borderline personality disorder (BPD). I explained to him that BPD is a historical term and that I believed that it did not mean that he could not recover from this and he was perfectly happy with this. In the treatment the focus was on what he took the abuse to mean about today and he fully recovered and has remained so 4 years post treatment. But I do agree that the evidence base for the standard treatments for BPD is wanting, it is impossible from the studies to gauge what proportion of clients no longer suffer from BPD for what period. Albeit that there are claims for impact on suicidality.
    It is not true that the diagnosis of BPD is unreliable, it has a perfectly acceptable kappa when a clinician blindly assesses a recording of a standardised semi-structured interview with a person Lobbestael et al 2011.

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          • I agree with this. In my own practice, I never “diagnosed” anyone except to make sure they got a kind of help we agreed they needed. And I told the client from the start that the “diagnoses” are just descriptions of what they already told someone and had no meaning beyond getting insurance reimbursement. Lacking a “diagnosis” never prevented any client I had from making progress. I’m guessing it made it easier for them to make progress, as I “normalized” their experiences and never gave the idea that there was something “wrong” with them that they couldn’t fix, which is the opposite of what these “diagnoses” do.

            What’s wrong with saying, “You get scared when you go outside” instead of “You have agoraphobia?” How does the latter help in any way?

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    • Why would any responsible person ever slap a BPD diagnosis on a client knowing just how abused it is by mental health community and society as a whole?

      Sure, possibly relying on the original, historic definition seems reasonable but this diagnosis is no longer viewed by industry and society by that framing definition.

      If your client ever needs further help and you aren’t available they will be brutalized when noting that diagnosis.

      Why didn’t you simply use a less stigmatizing diagnosis such as PTSD and then work within the antiquated or original diagnosis framework of BPD?

      You were already doing so when labeling the patient as BPD since it now carries an entirely different ‘bag’ with it now.

      Obviously you are an intelligent academic, but the real world implications of such a diagnosis are serious.

      There is absolutely no way your recovered patient is going to survive if they ever divulge previous diagnosis to anybody under any circumstances.

      Even on a social level. BPD is a death sentence for a person even in mental health community.

      Actually all of the mental health professionals I know personally (and it’s dozens from docs to social workers), there are only 2 people that I know of that will accept BPD clients. Those two, btw, originally social workers now MSW’s – those two are both BPD and bipolar. The one is horribly abusive as she floats from SSRI meds which don’t work, and the other is a a female MSW who is now embroiled in a sex scandal involving a client, just released from prison for heroin possession/abuse/addiction, came in for a drug addiction assessment with a different social worker and within a few weeks she had already started dating and had moved in with this freshly sober client.
      Obviously the social worker enablers in the agency who let this predatory BPD diagnosis MSW degreed woman sexually prey upon a client in the agency are just as guilty as the BPD MSW social worker, possibly more, because they sat by, said nothing. The agency was eventually shuttered over repeated sexual abuse by manager of the social workers he oversaw in the agency.
      Which does go to show us that “the doctors (and support staff) are crazier than the patients”.
      Every other professional I know refuses to work with BPD diagnosed persons.

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      • I agree with much of what you say, but I’m confused regarding the “historical” definition of BPD (“possibly relying on the original, historic definition seems reasonable…”)

        Wasn’t it always a highly stigmatized diagnosis? My understanding was that Kernberg or whoever “invented” it described it as a condition on the “borderline between neurosis and psychosis”? That it was only diagnosed in women, and that whoever added it to the DSM considered it untreatable (because supposedly it was ingrained into the patient’s personality?). And that “treatment” for it wasn’t covered by insurance until Linehan came along with her DBT?

        (For context, I think it’s a ridiculous diagnosis, revealing nothing about the patient and everything about the degree to which psychiatrists inflict their own negative feelings onto those they profess to help.)

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  6. I am totally opposed to anyone ‘slapping’ a diagnosis on anyone and have never done so. In the example I cited I shared my client the criteria for BPD and he felt it was a better descriptor of his difficulties than any other. He did not meet the DSM criteria for PTSD which for over 20 years it had been assumed he met, but nobody had carefully checked it out. I told him that in my view it was possible to recover from BPD, which indeed he did using the strategies detailed in the book.For the past 4 years he has been getting on with his life better than ever. It is the case unfortunately that a personality disorder label is commonly applied without any rigour and as if it is immutable. But used properly it can direct treatment efforts. Unfortunately all sorts of labels can be used pejoratively but that is not an argument against them per se.
    Historically it has been part of clinicians experiences to come across some people who appear to fit a BPD prototype. One response to this can be to insist that these clinicians have simply been wrong, but that would be a pathologising of most clinicians normal experience. Clearly for reliable use the prototype of BPD has needed refining to make sure we are all on the same page, that is precisely what diagnostic criteria are about. The fact that most clinicians have paid lip service to the criteria does not invalidate them.

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    • I still don’t get why it’s BETTER for him to call himself “BPD” rather than just identifying what he wants to change and exploring the possible roots and motivations for that behavior? What’s the benefit of calling himself “Borderline,” even if he selects that label for himself?

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    • Mike says, “Unfortunately, all sorts of labels can be used pejoratively, but that is not an argument against them per se.”

      That’s the typically specious argument used by people who refuse to admit psychiatric labels “per se” damage people’s lives.

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      • In the case of the DSM, the very nature of the “diagnoses” makes them diminishing and insulting automatically, as they presume the doctor is able to decide what is wrong with you lacking any concrete testing or evidence of anything being wrong at all. It’s hard to see how a label ever improves anyone’s psychological well-being, unless it’s a label they themselves choose to apply. I see nothing helpful about doctors or psychologists or counselors buying into the DSM fiction campaign.

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    • Wow, just wow.

      So you need those three letters to “explain” to a client?
      You can’t use actual dialogue, such as “let’s explore why you feel defensive”, etc etc?

      Nope, you been brainwashed, not actually realizing that any terms are useless. And PLEASE, let us not say that the “client agreed”, or they found it “helpful” when perhaps they went along with the garbage, totally unknowing, perhaps doing what they always did as a kid, feeling your power. Too much power to disagree with the “expert”.

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    • As psychiatrists told me for years every time I tried to explain the devastating consequences of being psychiatrized, including ECT, including having a BPD diagnosis slapped on me (which yes “slapped” is the correct verb. It was done as a punishment. The psychiatrist told me, “you have borderline personality disorder that’s why the ECT didn’t work.” That was the end of the appointment. He had nothing else to say. I had to go home and look up on my own what “borderline personality disorder” was), one person’s story has no relevance.
      Your patient’s experience, as you describe, is – as psychiatrists famously retort upon hearing another story of suffering from another victim of iatrogenic harm – anecdotal.

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    • “Unfortunately all sorts of labels can be used pejoratively but that is not an argument against them per se.”

      It is very much an argument against them. You cannot say you care about a person’s mental health and do exactly that which will bring all kinds of stereotypes and gaslighting into their life making their mental health deteriorate again.

      And also, please do not compare them with diagnoses or conditions in physical medicine. None of those pertain to a person’s character, conduct, personality or sanity.

      If I have pain during urination and I’m diagnosed with X or Y condition, after my kidney stone (assuming that’s what’s causing my pain) is removed, my diagnosis is nullified. How do you nullify a psychiatric “diagnosis”?

      The reality is, if you really wanted to, you could have helped the man as it is based on whatever problems he described. Please don’t say it can’t be done. It’s perfectly possible to do so. Is it harder because you don’t have a “diagnosis” to seek control over the patient? Are they useful as shorthand for you to observe patterns in people? Probably. But such terms make life harder for others too.

      Regardless, whether such labels go onto files must be the sole discretion of the person being labelled. Not the labellers, not family members, no one else. If a person is fine with being stamped with “Borderline Personality Disorder” or whatever else, more power to them. Don’t forcefully stamp those terms on people who don’t want them.

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      • And like lmc said: “If your client ever needs further help and you aren’t available they will be brutalized when noting that diagnosis.”

        You’re assuming that the rest of your profession or even non-psychiatry medical personnel who see those things in files or people in the legal system or families are going to be as ethical and understanding as you. The reality is, people don’t have the same mental health workers throughout. Once you’re gone, the headaches that come have to be borne by the people you’re categorising with that crap. People can’t rely on your mercy and charity to do the right thing when shit hits the fan. Heck, it would be tiring even for you to babysit people that your co-workers can simply wash their hands off of or get away by treating like crap. Ocassionally, somewhere inside, you’d curse yourself for having the burden of being the only “good guy” around and shouldering all that responsibility.

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  7. Of course there are some “insightful” clinicians who think giving “IT” a different name would be helpful.

    DUH and DUH. So like if i used to call you an “asshole” and now tell everyone I am changing “asshole” to “sweety”, then no one would know it’s the same thing? Wow

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